07 May 2025
GIRFT report found some trusts had moved to manipulating more displaced forearm fractures in the emergency department rather than in theatre. If more trusts adopted this more conservative approach to fracture management a significant amount of theatre time could be saved1.
Many uncomplicated paediatric clavicle fractures can be managed without x-rays2, and this is also considered true for toe fractures.
British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement3.
So, there is interest in understanding what the potential reductions in activity could be if trusts were to implement more conservative management of paediatric fractures.
Calculate the incidence of various fractures (forearm, elbow, clavicle, tibia/fibula and toe) recorded in emergency care in England.
Understand the trends in management of these fracture types over time.
Investigate the variation in management of these fracture types between trusts, and the opportunity for activity savings if there was more widespread conservative management.
The study population included those:
- who had attended an emergency department/urgent treatment centre in England between April 2019 and March 2024 AND
- were aged 16 and under AND
- had a SNOMED code for closed fractures of toe, clavicle, elbow, forearm or tibia/fibula recorded
Emergency care dataset (ECDS) linked with records in the Outpatient (OPA) and Admitted Patient Care Episode (APCE) datasets.
The coding of fractures is not sufficiently detailed and reliable to determine specific fracture types, and thus what would be the appropriate treatment at an individual patient level. However, we could calculate the proportion of children with each fracture type that:
Forearm fractures are the most common followed by elbow fractures.
Annual fracture incidence rates per 100,000 children
Type | Female | Female | Female | Male | Male | Male | Total |
|---|---|---|---|---|---|---|---|
Clavicle | 131 | 77 | 62 | 131 | 154 | 250 | 136 |
Elbow | 172 | 284 | 95 | 175 | 271 | 174 | 197 |
Forearm | 270 | 786 | 362 | 273 | 828 | 1,024 | 622 |
Tibia/Fibula | 174 | 72 | 71 | 213 | 76 | 171 | 124 |
Toe | 17 | 125 | 160 | 26 | 142 | 281 | 135 |
Total | 764 | 1,344 | 750 | 818 | 1,471 | 1,900 | 1,214 |
Tibia/Fibula fractures are most common in those aged 0-4 years, while elbow fractures are most common in those aged 5-10 years
In the 11-16 year old age group all fracture types are more common in males compared to females, with males aged 11-16 yrs old having the highest incidence of clavicle, forearm and toe fractures.
For all fracture types incidence rates increase in the summer months (June-Aug, highlighted in yellow), likely due to increases in children participating in physical activities.
Percentage of emergency care attendances with a diagnosis code for those aged 16 or under, where the recorded code is for a fracture.
There is considerable variability between providers in the percentage emergency care attendances where a fracture is recorded, even when accounting for the different rates of recording diagnoses seen between trusts.
These differences could be due to:
Alternative provision locally, e.g. in some areas there is independent urgent care provision available.
Regional differences in fracture rate, which may be related to levels of physical activity, visitors from out of area and the demographic of the area.
Fracture diagnoses being disproportionately recorded by trusts.
ICB | Clavicle | Elbow | Forearm | Tibia/Fibula | Toe | Total | % of ED attendances |
|---|---|---|---|---|---|---|---|
NHS Cornwall and the Isles of Scilly ICB | 220 | 365 | 1,136 | 177 | 262 | 2,159 | 1 |
NHS Herefordshire and Worcestershire ICB | 201 | 308 | 1,016 | 142 | 269 | 1,934 | 22 |
NHS Shropshire, Telford and Wrekin ICB | 215 | 292 | 971 | 139 | 230 | 1,847 | 24 |
NHS Gloucestershire ICB | 222 | 186 | 1,004 | 183 | 205 | 1,800 | 37 |
NHS Derby and Derbyshire ICB | 185 | 256 | 905 | 169 | 232 | 1,747 | 13 |
NHS Somerset ICB | 195 | 280 | 925 | 150 | 190 | 1,740 | 18 |
NHS Dorset ICB | 188 | 280 | 857 | 145 | 194 | 1,664 | 26 |
NHS South Yorkshire ICB | 192 | 305 | 803 | 169 | 193 | 1,662 | 18 |
NHS Norfolk and Waveney ICB | 198 | 281 | 842 | 167 | 165 | 1,653 | 8 |
NHS Devon ICB | 188 | 262 | 871 | 163 | 150 | 1,634 | 23 |
NHS Black Country ICB | 164 | 304 | 818 | 148 | 144 | 1,578 | 42 |
NHS Sussex ICB | 162 | 241 | 825 | 128 | 171 | 1,528 | 16 |
NHS North East and North Cumbria ICB | 146 | 232 | 748 | 148 | 186 | 1,460 | 26 |
NHS Humber and North Yorkshire ICB | 187 | 213 | 727 | 136 | 162 | 1,425 | 18 |
NHS Lincolnshire ICB | 146 | 214 | 736 | 134 | 187 | 1,417 | 6 |
NHS Coventry and Warwickshire ICB | 174 | 189 | 717 | 146 | 149 | 1,375 | 16 |
NHS Bedfordshire, Luton and Milton Keynes ICB | 132 | 246 | 688 | 110 | 146 | 1,322 | 22 |
NHS Greater Manchester ICB | 140 | 196 | 708 | 114 | 164 | 1,322 | 32 |
NHS Mid and South Essex ICB | 138 | 215 | 660 | 163 | 137 | 1,312 | 6 |
NHS Cheshire and Merseyside ICB | 150 | 221 | 661 | 139 | 141 | 1,311 | 31 |
NHS Hampshire and Isle of Wight ICB | 134 | 231 | 638 | 139 | 125 | 1,267 | 19 |
NHS West Yorkshire ICB | 156 | 200 | 621 | 132 | 133 | 1,243 | 23 |
NHS Birmingham and Solihull ICB | 127 | 236 | 603 | 123 | 142 | 1,232 | 18 |
NHS Bristol, North Somerset and South Gloucestershire ICB | 125 | 226 | 589 | 177 | 91 | 1,208 | 7 |
NHS Nottingham and Nottinghamshire ICB | 131 | 216 | 597 | 150 | 114 | 1,208 | 13 |
NHS Northamptonshire ICB | 144 | 202 | 578 | 97 | 118 | 1,139 | 13 |
NHS Bath and North East Somerset, Swindon and Wiltshire ICB | 145 | 191 | 571 | 116 | 94 | 1,117 | 24 |
NHS South West London ICB | 130 | 111 | 569 | 149 | 141 | 1,101 | 39 |
NHS Cambridgeshire and Peterborough ICB | 146 | 179 | 550 | 99 | 120 | 1,094 | 45 |
NHS Suffolk and North East Essex ICB | 145 | 157 | 523 | 106 | 129 | 1,060 | 27 |
NHS Lancashire and South Cumbria ICB | 122 | 170 | 530 | 124 | 107 | 1,052 | 31 |
NHS Hertfordshire and West Essex ICB | 110 | 150 | 506 | 100 | 113 | 980 | 22 |
NHS Surrey Heartlands ICB | 130 | 162 | 460 | 102 | 115 | 970 | 31 |
NHS Leicester, Leicestershire and Rutland ICB | 99 | 168 | 446 | 128 | 94 | 934 | 2 |
NHS Staffordshire and Stoke-on-Trent ICB | 87 | 121 | 503 | 88 | 125 | 923 | 12 |
NHS North Central London ICB | 92 | 135 | 438 | 107 | 92 | 864 | 34 |
NHS Kent and Medway ICB | 85 | 104 | 440 | 63 | 109 | 801 | 48 |
NHS North West London ICB | 82 | 132 | 393 | 88 | 74 | 770 | 38 |
NHS Buckinghamshire, Oxfordshire and Berkshire West ICB | 84 | 116 | 356 | 78 | 55 | 689 | 39 |
NHS Frimley ICB | 70 | 118 | 327 | 77 | 46 | 639 | 35 |
NHS South East London ICB | 62 | 103 | 293 | 72 | 69 | 598 | 23 |
NHS North East London ICB | 59 | 121 | 276 | 80 | 47 | 584 | 33 |
Incidence rates appear to vary by ICB area, but lower rates in some area may be the result of some trusts in those areas not reliably recording diagnoses codes for emergency care attendances.
In children forearm fractures are the most common followed by elbow fractures.
Fractures of tibia/fibula are most common in under 5
Elbow fractures are most common in 5-10 yr olds
For older children the fracture rate is higher in boys compared to girls, with boys aged 11-16 yrs having the highest rates of clavicle, forearm and toe fractures.
Higher fractures rates are seen in the summer months, likely related to increased outdoor physical activity.
Fracture incidence rates vary by ICB region and by trust- this is due to low levels of recording of diagnoses in emergency care at some trusts, but availability of alternative provision locally and regional differences in fracture rates may contribute.
Majority of fractures are x-rayed in the emergency department
Very little change in the percentage over time
Trend towards a reduction in the number upper limb fractures where a follow-up appointment is given.
As a result of the COVID-19 pandemic the proportion of follow up appointments conducted face-to-face has fallen significantly.
Odds Ratio | Confidence Intervals | P value | |
|---|---|---|---|
(Intercept) | 2.20 | 2.15 to 2.25 | <0.001* |
Sex | |||
Female | 1.00 | Reference | |
Male | 1.12 | 1.11 to 1.13 | <0.001* |
Age | |||
5-10 yrs | 1.00 | Reference | |
0-4 yrs | 0.96 | 0.94 to 0.97 | <0.001* |
11-16 yrs | 1.15 | 1.13 to 1.16 | <0.001* |
Ethnicity | |||
White | 1.00 | Reference | |
Asian or Asian British | 1.05 | 1.03 to 1.08 | <0.001* |
Black or Black British | 1.14 | 1.1 to 1.19 | <0.001* |
Mixed | 1.01 | 0.98 to 1.05 | 0.34 |
Other Ethnic Groups | 1.00 | 0.97 to 1.04 | 0.86 |
Missing/Unknown | 0.97 | 0.95 to 0.98 | <0.001* |
IMD Quintiles | |||
1- Most deprived | 1.00 | Reference | |
2 | 1.08 | 1.07 to 1.1 | <0.001* |
3 | 1.03 | 1.01 to 1.04 | <0.001* |
4 | 1.05 | 1.04 to 1.07 | <0.001* |
5- Least deprived | 1.08 | 1.06 to 1.1 | <0.001* |
Department type | |||
Major Emergency Department | 1.00 | Reference | |
Urgent Treatment Centre/Walk in centre | 0.96 | 0.95 to 0.98 | <0.001* |
Day of the week | |||
Week | 1.00 | Reference | |
Weekend | 1.06 | 1.05 to 1.08 | <0.001* |
Time of day | |||
Day 7am-7pm | 1.00 | Reference | |
Night 7pm to 7am | 1.12 | 1.1 to 1.13 | <0.001* |
Time of year | |||
Autumn | 1.00 | Reference | |
Winter | 0.94 | 0.93 to 0.96 | <0.001* |
Spring | 0.95 | 0.94 to 0.97 | <0.001* |
Summer | 0.99 | 0.97 to 1 | 0.06 |
Year | |||
2019/20 | 1.00 | Reference | |
2020/21 | 0.85 | 0.83 to 0.86 | <0.001* |
2021/22 | 0.79 | 0.77 to 0.8 | <0.001* |
2022/23 | 0.72 | 0.71 to 0.73 | <0.001* |
2023/24 | 0.72 | 0.71 to 0.73 | <0.001* |
Fracture type | |||
Clavicle | 0.79 | 0.78 to 0.8 | <0.001* |
Forearm | 1.00 | Reference | |
Elbow | 2.47 | 2.43 to 2.52 | <0.001* |
Tibia/Fibula | 2.09 | 2.05 to 2.14 | <0.001* |
Toe | 0.37 | 0.36 to 0.37 | <0.001* |
Children are more likely to be given a follow-up appointment if they are
male
11-16 yrs old
from an asian or black background
living in a less deprived area
They are also more likely to have a follow-up appointment if they attended
an emergency department
on a weekend
at nighttime
Those attending in more recent years were less likely to have a follow-up appointment, further indicating there has been a move towards fewer follow-up appointments.
The proportion of forearm fractures manipulated in the emergency department has increased and the proportion manipulated in theatre has decreased.
For forearm fractures currently over half of all manipulations are performed in the emergency department.
The total number of manipulations for forearm fractures has reduced.
Odds Ratio | Confidence Intervals | P value | |
|---|---|---|---|
(Intercept) | 5.87 | 5.29 to 6.52 | <0.001* |
Sex | |||
Female | 1.00 | Reference | |
Male | 0.93 | 0.88 to 0.99 | 0.01* |
Age | |||
5-10 yrs | 1.00 | Reference | |
0-4 yrs | 1.62 | 1.48 to 1.77 | <0.001* |
11-16 yrs | 0.51 | 0.48 to 0.54 | <0.001* |
Ethnicity | |||
White | 1.00 | Reference | |
Asian or Asian British | 0.81 | 0.73 to 0.91 | <0.001* |
Black or Black British | 0.49 | 0.41 to 0.59 | <0.001* |
Mixed | 0.69 | 0.6 to 0.8 | <0.001* |
Other Ethnic Groups | 0.54 | 0.46 to 0.62 | <0.001* |
Missing/Unknown | 0.85 | 0.78 to 0.93 | <0.001* |
IMD Quintiles | |||
1- Most deprived | 1.00 | Reference | |
2 | 0.76 | 0.7 to 0.82 | <0.001* |
3 | 0.71 | 0.66 to 0.77 | <0.001* |
4 | 0.68 | 0.63 to 0.74 | <0.001* |
5- Least deprived | 0.62 | 0.57 to 0.67 | <0.001* |
Department type | |||
Major Emergency Department | 1.00 | Reference | |
Urgent Treatment Centre/Walk in centre | 5.12 | 4.58 to 5.74 | <0.001* |
Day of the week | |||
Week | 1.00 | Reference | |
Weekend | 1.09 | 1.03 to 1.15 | <0.001* |
Time of day | |||
Day 7am-7pm | 1.00 | Reference | |
Night 7pm to 7am | 1.12 | 1.04 to 1.2 | <0.001* |
Time of year | |||
Autumn | 1.00 | Reference | |
Winter | 0.87 | 0.8 to 0.95 | <0.001* |
Spring | 1.06 | 0.99 to 1.14 | 0.09 |
Summer | 1.17 | 1.09 to 1.25 | <0.001* |
Year | |||
2019/20 | 1.00 | Reference | |
2020/21 | 0.43 | 0.4 to 0.47 | <0.001* |
2021/22 | 0.41 | 0.38 to 0.45 | <0.001* |
2022/23 | 0.28 | 0.26 to 0.3 | <0.001* |
2023/24 | 0.20 | 0.18 to 0.22 | <0.001* |
Children are more likely to have a fracture manipulated in theatre if they are
female
under the age of 5
white
living in a more deprived area
They are also more likely to have a manipulation in theatre if they attended
an urgent treatment centre
on a weekend
at nighttime
in the summer
Those attending in more recent years were less likely to have their fracture manipulated in theatre, further indicating there has been a move towards manipulating more fractures in the emergency department.
No change over the last 5 years in the proportion of fractures being x-rayed.
Slight reduction in the proportion of fractures given a follow up appointment, but significant increase in the proportion that are conducted virtually since the pandemic.
Over the last 5 years the proportion of fractures manipulated in theatre has decreased and the proportion manipulated in the emergency department has increased.
The overall manipulation rate for forearm fractures has reduced over the last 5 years.
Overall, there is a trend towards more conservative management of paediatric fractures.
Percentage of clavicle fractures x-rayed
Min | 5.9 % |
1st quartile | 87.7 % |
Median | 93.2 % |
3rd quartile | 95.7 % |
Max | 100 % |
Reducing the percentage of x-rays to the level of the lowest decile of trusts (77.3%) would give an annual reduction in England of 1,986 (15.5%) x-rays.
Percentage of toe fractures x-rayed
Min | 2.4 % |
1st quartile | 72.6 % |
Median | 82.4 % |
3rd quartile | 89.7 % |
Max | 100 % |
Reducing the percentage of x-rays to the level of the lowest decile of trusts (62.3%) there would give an annual reduction in England of 2,412 (22.5%) x-rays.
Min | 19.8 % |
1st quartile | 56.2 % |
Median | 65.1 % |
3rd quartile | 77.2 % |
Max | 98 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (46%) would give an annual reduction in England of 13,768 (30.7%) follow-up appointments.
Min | 25.9 % |
1st quartile | 74.2 % |
Median | 83.6 % |
3rd quartile | 90.4 % |
Max | 100 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (61.8%) would give an annual reduction in England of 4,486 (25.8%) follow-up appointments.
Min | 5.6 % |
1st quartile | 46.5 % |
Median | 61.2 % |
3rd quartile | 82.2 % |
Max | 97.4 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (31.4%) would give an annual reduction in England of 4,440 (49.9%) follow-up appointments.
Min | 20.2 % |
1st quartile | 72.8 % |
Median | 83.7 % |
3rd quartile | 90.1 % |
Max | 100 % |
Reducing the percentage of follow-ups to the level of the lowest decile of trusts (60%) would give an annual reduction in England of 2,817 (26.4%) follow-up appointments.
Min | 11.1 % |
1st quartile | 31.7 % |
Median | 45.4 % |
3rd quartile | 56.9 % |
Max | 100 % |
Reduced the percentage of follow-ups to the level of the lowest decile of trusts (21.3%) would give an annual reduction in England of 3,260 (53%) follow-up appointments.
Total annual reduction of 28,771 follow-up appointments in England.
This may be an underestimation as number of children may have more than one follow-up appointment that could be deemed unnecessary.
Min | 0.2 % |
1st quartile | 2.3 % |
Median | 4.4 % |
3rd quartile | 6.5 % |
Max | 21.4 % |
There could be an annual reduction in England of 1,747 (54.5 %) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (2.3%).
NOTE: Very low numbers at many providers
Min | 0 % |
1st quartile | 0.5 % |
Median | 1.3 % |
3rd quartile | 2 % |
Max | 8.8 % |
There could be an annual reduction in England of 177 (67%) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (0.5%).
Clavicle | Elbow | Forearm | Tibia/Fibula | Toe | Total | |
|---|---|---|---|---|---|---|
Reduction in x-rays in emergency care | 1,986 (15.5%) | - | - | - | 2,412 (22.5%) | 4,398 (18.7%) |
Reduction in follow-up appts | 4,440 (49.9%) | 4,486 (25.8%) | 13,768 (30.7%) | 2,817 (26.4%) | 3,260 (53%) | 28,771 (32.7%) |
Reduction in manipulations in theatre | - | 177 (67%) | 1,747 (54.5%) | - | - | 1,924 (55.4%) |
Potential to reduce the number of x-rays of clavicle and toe fractures in the emergency department in England by around 4,400 per year.
Potential to be reduce the number of fracture follow-up appointments in England by at least 28,800 per year. This is based on first follow-up appointments but there are potential further savings as many children appear to have having multiple follow-up appointments.
While the number of forearm and elbow fractures manipulated in theatre has significantly decreased there is still potential to further reduce manipulations in theatre by around 1,900 a year in England.
While trusts have already implemented more conservative management of paediatric fractures, others that could still benefit from adopting this approach.
It is possible some of our numbers may be underestimates due to some issues with coding/reporting especially as diagnoses codes are not always recorded in the emergency care dataset. For example the number of manipulations of elbow fractures in theatre is considered low, this may be a coding issue or related to the inability from the coding to determine which radial fractures should be classed as elbow rather than forearm fractures.
Our incidence rates are for closed fractures only, open fractures, pathological fractures and birth trauma fractures were excluded.
Coding of fractures is not specific enough to determine at an individual level which fractures could be managed more conservatively, so we are relying on comparing proportion between trusts. Some fractures will be more complex and require manipulation and follow-up, but we can’t be sure whether all trusts have a similar proportion of more complex fractures.
Only closed manipulations without internal fixation are included in our data, so if some trusts are treating a higher proportion of fractures with internal fixation then their rate of closed manipulations could appear lower. We have also not included re-manipulations in our data.
There will be a small number of cases where a child has more than one fracture or other injuries.
It should be noted is that data is allocated to the trust where the child attended the emergency department, but where they were followed-up if that is different